Wounded Warriors: Their Last Battle By Deborah Grassman ARNP Bay Pines VAMC Bay Pines, Florida 33744

Transcription

1 Wounded Warriors: Their Last Battle By Deborah Grassman ARNP Bay Pines VAMC Bay Pines, Florida He had fractured his clavicle by simply turning his head. Later, he similarly fractured his arm. Fred had weakened bones throughout his cancer-riddled skeleton. Despite these hardships, his wife, Peggy, managed his care at home, driving him 100 miles to the VA for treatments. While he was hospitalized, Fred was pivoting to a bedside commode when his thigh bone broke. Howling in pain, he shifted his weight to the other leg. In an instant, his hip broke too. Peggy heard the bones snap and was beside herself. I took her out of the room while staff worked to stabilize his fractures. This is so unfair, I told Peggy tearfully. Fred doesn t deserve this. I could see Peggy took comfort in these words, as I validated the suffering she was feeling. I don t know what we ve done to deserve this, she said softly. We continued to express our dismay. Having confronted her own feelings, Peggy was then able to return to the room to comfort Fred. A few days later, we needed to lift Fred to a special mattress. I shut the door and told him to scream or do whatever he needed to help him with the pain. But Fred had been a soldier in World War II. He knew what it took to survive, and the way soldiers survive is through sheer grit and determination. He never made a sound. While held aloft in a lift, gritting his teeth, face knotted tightly in pain, he winked at me, How ya doin Deb? I was stunned by his stoicism. I had seen it with hundreds of other veterans. Veterans who refused pain medication. Veterans who were wincing in pain and yet when asked, replied I can handle it or It s just a little discomfort. For some, the more pain the better proof of just how strong they were. Breaking down to take pain medication signified failure. The military seemed to magnify the big boys don t cry attitudes already instilled in little boys; male soldiers received a double dose of macho. Fred died a few days later, never complaining. His face remained taunt until the last hours of life when stoicism finally yielded to the peace and freedom of death. I remained haunted by his determination to not succumb to what he was experiencing.fighting until the bitter end. Stoicism I realized I had often admired the stoicism I witnessed in veterans. They were often non-complaining, grin and bear it types that endured their sufferings silently. The few times tears or fears broke through their façades, they felt embarrassed, apologized, and quickly re-retreated. Walls offered protection. Yet, I noted their fight to the bitter end attitudes sometimes meant just that fighting to bitter deaths. Attack and defend instincts made death the enemy and dying a battle. Survival mode mentality interfered with letting go. When backed into a corner, soldiers weren t conditioned to surrender. They were conditioned to fight.

2 I had never attempted to broach, much less breach stoic façades. It was something in Fred s eyes that made me question my wisdom in failing to do so. As I struggled with his memory, my admiration for stoicism ceded to wonderment. Could stoicism contribute to the agitation and lack of peace I sometimes witnessed as veterans died? While I was busy praising veterans for being good patients because they seldom cried, complained of pain, or spoke of fear, was I reinforcing facades that interfered with their real needs? While I was reinforcing the façade, was I missing an opportunity to teach them how to let go? Would that teaching be different for veterans because of their don t surrender training? Stoicism is important on the battlefield. But I have to ask myself, what about after the battle is over and the soldier becomes a husband, a father, or a dying human being? Downplaying their suffering and ashamed of weak feelings, veterans often confused stoicism with courage. They didn t realize it takes courage to own feelings; weakness and cowardice to dis-own, pretend, or hide them behind stoic walls. I decided to get better acquainted with this wall of stoicism I encountered so frequently in veterans. I began with the dictionary. Stoic: showing indifference to joy, grief, pleasure, pain. 1 I was staggered with the implications of the meaning. Like spores that entomb potential energy and growth, stoicism walled off vitality - dividing inward and outward selves. Families had complained about it often. It was then I realized that death was not the enemy. The enemies were those things that interfered with a peaceful death. Stoicism was at the top of that list at least with veterans at least from my vantage point. I decided then, I had to try to breach the wall. I might make some mistakes. I might fail. But too often I had seen stoicism rob people of a peaceful death. Too often I had seen stoicism rob people of their inward selves. Too often I had seen stoicism keep people trapped in isolation, disconnected from those they loved. No more One day, a physician asked me to convince a patient named Steve to attend a meeting of our emotional support group. He s depressed but he won t tell me what s wrong, the doctor said. The group will cheer him up. Steve had malignant melanoma. His treatment had failed. Luckily for Steve, I d grown beyond my earlier stage of trying to cheer up depressed patients. I entered the room ready to accept Steve s feelings, willing to explore them with him. With downcast eyes and a flat voice, he told me how alone he felt. I feel like I m letting my family down, he said. I m a fighter and they keep telling me to keep it up, but I can t do it any longer. I feel so alone in all of this. Recognizing the stoic wall for the isolation it was creating, I carefully and cautiously offered a crack: Are you ready to die, Steve? He nodded his head slowly. You need to know it s okay to die. If your time has come, then it s a matter of getting ready now, I said gently. He looked in my eyes for the first time. Maybe you could tell your family you can t fight anymore and you need their help so you can die peacefully. I can t, he said, shaking his head. That would be giving up. I can never surrender.

3 Surrender isn t good on a battlefield, I acknowledged. But this isn t a battlefield, Steve. Death is a natural part of life. It s a very important part of life. You don t have many days left, so every day is precious. You might not want to waste one by hiding, fighting, or pretending. I know your instincts are to fight. But relaxing and letting go might help you have a peaceful death. Hesitantly, he nodded cautiously considering the possibility. Would it make it easier if I told your family in your presence? Then you could talk about it together Slowly he nodded his head yes. When his wife and daughter arrived, I ventured forth: As you ve probably noticed, in spite of everything we re doing, Steve s been getting weaker. He s getting tired. He s too weary to fight any more. But he feels like if he quits, he s letting you down... As I spoke, his daughter (who was pregnant) started to cry. I paused, giving them time to absorb what I was saying before I continued. He s nearing the end of his life and he needs your permission to give up the fight. He s got a lot to face and he wants your help. When I finished, his daughter turned to her father and apologized for having told him to keep fighting. She explained she d wanted her unborn baby to know his grandfather to know what a fine man he was. She went on to say how her love for him would live on in her child. In the span of a few minutes, the value of Steve s life was affirmed, his suffering validated, and he was re-connected with himself and those who loved him. The daughter then hugged me, sobbing in my arms. Thank you for caring enough to not let Daddy die alone. I accepted her gratitude, silently thanking Fred and the hundreds of other veterans for what they had taught me. Steve did not have to die alone behind that wall after all. I began to realize how veterans stories had festered, creating unknown turmoil and inner havoc. They sometimes felt ashamed that they didn t know how to cope, carrying turmoil around with them like a secret. They often suffered silently or distanced themselves with anger. Repeatedly I attempted to penetrate the wall to reach the vitality I knew lived beyond it. It had to be done carefully. The primary chisel was trust especially with combat veterans. Veterans traumatized by war don t trust easily. They ve been taught not to trust. Betray a combat veteran once, and you become the enemy. I also noted stoic walls were maintained with building blocks of stubborn pride, conquering control, and fierce independence. Anything threatening pride, control, or independence was rejected - either silently or angrily. Death is a humbling experience. Loss of control, pride, and independence are part of the dying process. Sooner or later, the wall has to crumble. Later means a fight to the bitter end ; sooner means a weary soldier is finally able to come home. It means scattered pieces of inward self hidden behind walls or exploded during wars were finally able to make peace with each other at last. Helping Soldiers Make Peace When I do Hospice consults in the hospital or admit a patient to the Hospice unit, I elicit three perspectives from the patient: - A sense of their past story, including how the military might have impacted them. - Their current relationship to the dilemma they are facing with poor health, including their identification of their most pressing need. - Hopes for their future, including what they need so they can die healed

4 Creating a Safe Emotional Environment Throughout interactions with veterans, I assess for barriers interfering with anticipated peacefulness. After most of the questions, especially those related to trauma, I sit quietly for several seconds so they do not feel pressured. Penetrating stoic walls or opening doors to trauma must be done sensitively and respectfully. My job is to create a safe and comfortable environment whereby patients feel comfortable emerging emotionally if they so choose. I can do damage if I push. Far more frequently, I observe damage done by healthcare providers not recognizing the significance of military history and its impact on end-of-life care; this is called abandonment; it also causes harm. My job is to open the door without pushing. These are some of the ways I ve found effective. Questions related to Military History: Tell me a little bit about how things went for you in the military How have your experiences in the military molded and shaped your life? You probably saw a lot of ugly things in that war. Is there anything that might still be troubling you a little bit now? Some combat veterans have told me they lost their soul in that war. Did anything like that sort of happen with you? Many veterans who ve not been in combat have sustained other kinds of trauma. Are there any traumas that you ve sustained that might still be troubling you a bit? Now is a time to look back over your life. Is there anything that might still be troubling you?...anything about the war that might still be haunting you a little bit? Family as Resource Many people with PTSD surround the trauma imprint with a wall of silence. Offering some quotes by other veterans may be able to give voice to their stories. Sometimes, a vet will tell me he lost his soul in Vietnam. Did something like that sort of happen with you? Then sit silently. (Other common quotes that can be used are: 90% of me died in that war. ; I lost my soul in the war. ) Families are also a source for their experiences of war. A door can be opened with offering a quote heard by other family members: Some families have told me Most of my brother remained in Vietnam or I didn t know the person who came back. Have you experienced anything sort of like that? Penetrating Stoic Walls En-courage them to consider softening prideful ways so transitions can be navigated. Encourage them not to confuse stoicism with courage. Anyone can hide behind a stoic wall of silence. It takes courage to reach out to connect with others or say I m sorry or I m wrong Do you find it difficult to own your mistakes? You sound like a rather stubborn guy. Are you the kind of person who has a hard time compromising with others because when you do it feels like you re surrendering the battle giving up? Sounds like pride might be keeping you stuck getting in the way of things going better for you. Give them choices and recognize the opportunity to penetrate stoicism by acknowledging their lack of control. Your world has changed a lot. It s really shrinking

5 I find it hard to accept that some things are beyond my control. Tell me how you re doing with that It can be hard to wait for death to come to know it s not on your timetable It s tough to realize we can t control the world that we re not God Sometimes veterans tell me feeling helpless makes them angry. I imagine it s hard for a soldier to learn how to surrender to let go Don t try to affirm their self-sufficiency. It only reinforces independence they no longer have. Instead, validate their suffering and en-courage reckoning: It s hard to not be able to do things for yourself any more It s not easy to be at the mercy of others now Some veterans tell me asking for help is humiliating. Tell me how helplessness makes you feel... Are you the kind of person who can accept things are changing and ask for help or do you sometime try to pretend nothing has changed and things can go back to the way they used to be? Affirming and Validating Feelings I know it can be hard for men to express their feelings. But, now is not a time to pretend like nothing is going on.that nothing has changed. It may be difficult to express the hurt you may be feeling. It may be tempting to try to hide it and act like everything is going on like normal. It takes a lot of energy to pretend. Now is a time when you might want to consider letting yourself be honest with yourself and maybe with a few others too Are you willing to own your (pain, fear, guilt)? There s no shame in feeling your feelings. The shame is in not sharing them with those who love you. The shame is in not asking for help when you need it. The shame is in not recognizing your needs when you have them. How s your heart today your inward heart? I can see you are comfortable talking about the (hurt, anger, guilt, helplessness, etc.). I m wondering if there are ever times when you let yourself feel your (hurt, anger, guilt, helplessness) when you let it move down from your head to your heart? Empowering silent voices: If your (anger, fear, cancer, liver, Deeper Self) could speak, what might it say? I know you said you feel fine ; but you don t sound like you really mean it I noticed you sighed as you said it. Normalizing feelings (conveying the naturalness and healthfulness of owning and expressing feelings): Many veterans tell me they feel (angry, scared, sad, guilty) when something like this happens. It may be tempting to try to hide your feelings and act like everything is normal. It takes energy to pretend. Now is a time when you might want to consider letting yourself be honest with yourself to be real, I might say to en-courage them. Scaling feelings. On a 0-10 scale, what number is your (anger, guilt, pain, fear, helplessness)? Don t try to reduce that number. Instead, ask them to tell you what their (anger, guilt, pain, fear) is telling them. Don t try to lower a 10 feeling of helplessness by asking them what they can do to feel less helpless. This encourages them to hold onto what is not holdable. Rather, en-courage coming to peace with the helplessness of dying

6 by asking them to consider what they need to let go of and what new things might they want to hold onto now that their situation has changed. Guilt. Veterans often bear much guilt which often interferes with peace of mind and peace of heart. ( If only I would have, he d still be here today. If only. If only. If only Why him and not me? ) Rather than taking the guilt away, guilt can lead toward remorse and forgiveness. Utilize the process of forgiveness to restore peace. Include the 7 steps of Living and Dying Healed ( Forgive me, I forgive you, I love you, Thank you, and Goodbye, Let go, Open up ) 2. Encouraging a different relationship with death Fighting attitudes were important on the battlefield, but you re not on a battlefield now. It s okay to surrender to let go so you can have a peaceful death Hospice: A Time of At-one-ment With a supportive environment and staff who know how to respond to the unique and not-so-unique needs of veterans, I have found that most veterans do, indeed, die healed. Combat veterans sometime have special needs that complicate their deaths. Simple words, said compassionately and with understanding, can often unlock doors, bringing light into dark places. I was in the National Museum of Vietnam Art in Chicago. I saw a caption on a painting by a veteran that I believe summarizes the work of healthcare providers responding to the needs of combat veterans at the ends of their lives: Hoping and wishing you can settle this whole thing in your mind about this war resolving it within yourself before the time of atonement comes, weeping and crying at the end of your life. References 1 Webster s New World Dictionary. (1994). NY: Simon & Schuster. 2 Byock, Ira. (1997). Dying Well. NY: Riverhead Books. Byock identifies the first 5 steps. I ve added let go and open up because I believe they reflect the purpose for doing the first 5 steps. 3 Ron Mann. Atoning in the National Vietnam Museum of Art, Chicago.